Basic Information
| Provider Information | |||||||||
| NPI: | 1215367537 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAVARD | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | M.ED., BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10926 S TRYON ST STE E | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282734154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552015498 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15202 KESTRELCREST CT | ||||||||
| Address2: | |||||||||
| City: | LITHIA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335474817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035287679 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2013 | ||||||||
| LastUpdateDate: | 07/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 023360100 | 05 | FL | MEDICAID |